Reaching the marginalised in the race to zero – zero infections, discrimination, and AIDS related-deaths

More people than ever before can now access HIV and AIDS treatment, on World Aids Day guest blogger Ellen Bajenja of ACORD asks if this reflects the reality for marginalised communities in sub-Saharan Africa?

The UNAIDS report, How to get to zero: Faster. Better. Smarter, released ahead of World AIDS Day 2011, includes good news for actors in the HIV and AIDS response. More people than ever before can now access treatment - 6.6 million people of the estimated 14.4 million affected in low- to middle-income countries are now receiving antiretroviral drugs or ARVs. And increased access to ARVs is reported to have translated into fewer AIDS-related
deaths (21 per cent reduction in cases recorded from the peak year of 2005). This is certainly an indication of a positive trend in the epidemic response.

In spite of these achievements, more efforts by actors are required to realize the ambitious goal of zero new HIV infections, zero stigma and zero AIDs deaths. How long this will take will certainly depend on how well governments, civil society organisations, and the donor community are able to deal with the intricacies of the epidemic's progression, which are still evident in the affected regions. Until now, biomedical and behavioural studies have greatly contributed to defining the course of action in the response but have been limited in predicting the future
direction for the epidemic.

The 'Mainstreaming AIDS programme in East and Central Africa' (MAIN) is a joint programme between ACORD, Oxfam and partners focusing on addressing the impacts of HIV and AIDS in hard-to-reach communities in Burundi, The Democratic Republic of Congo, Rwanda, Tanzania and Uganda.

Target groups include populations that are excluded from social services in general, either as a result of their geographical accessibility or due to social, cultural, economic and political factors. Communities include pastoralists, fishing communities, women victims of gender-based violence, child-headed households, commercial sex workers, men who have sex with men, and lesbian, gay, bisexual and intersex people.

The programme aims to protect the rights of such groups to access HIV prevention, AIDS treatment and care services and livelihoods opportunities. It also aims to reduce the risk of HIV transmission and the impact of AIDS for affected populations.

As an actor in the HIV and AIDS work, I have often wondered whether national averages in access to services can be a basis for understanding the realities of the epidemic within specific marginalised communities. The UNAIDS report indicates reductions in infections occurring in sub-Saharan Africa (SSA), a region acutely affected by the epidemic. But cases of limited access to prevention, treatment and care services are still evident there.

There are marked variations within national prevalence rates in different regions within countries particularly where populations have been affected by conflict, sexual and gender-based violence, and poverty, among other factors. Therefore when countries report improvements in prevalence rates, success in access to prevention, treatment and care for populations living with and affected by HIV and AIDS, these figures may not be inclusive of specific marginalised populations.

While averages can be seen to be improving, the situations of the marginalised communities may be opposite. After three decades of the response, countries in SSA are still faced with unresolved challenges including stigma and discrimination, criminalizing laws and policies, cases of sexual and gender-based violence, poverty and economic inequality, among other factors known to fuel the epidemic.

According to the UNAIDS World AIDS Day Report 2011, 60 per cent of people living with HIV do not know their HIV status. Why, then, do we wonder that, in spite of their commitments to achieve universal access to services, governments are still blind to the realities of HIV and AIDS transmission?

In view of prevailing resource limitations, UNAIDS has designed a framework for ensuring maximum benefits from the current responses, by recommending a focus on high-impact, evidence-based and high-value strategies. However in my view, these interventions can only be effective if countries objectively address the underlying realities of their local contexts. Interventions can be effective if discrimination against some marginalised but most at risk groups in countries in SSA is addressed. How will countries with population groups excluded from services ensure effective
prevention, treatment and care for all citizens? How will countries depending on an externally-funded health sector address the factors that lie beyond health but have a major impact on the epidemic spread? In the wake of reduced donor funding, how will countries maintain the momentum to zero HIV infection, stigma and discrimination and AIDS-related deaths?

Answers to these questions lie in understanding the inherent links in the social, economic and political contexts and their impact on the epidemic spread. The mainstreaming approach - which focuses on redesigning core programs to address the causes and consequences of HIV and AIDS risks and vulnerabilities - is central to this process. Through the mainstreaming process, we can develop an understanding of how HIV and AIDs affects the communities we work with, as well as our institutions.

As we commemorate yet another World AIDS Day, it may be critical for all actors to review their approaches to addressing HIV and AIDs, even in situations of financial limitations. How have we addressed HIV and AIDs in our work? What are the most cost effective strategies for enabling us to maintain AIDS on the agenda in the midst of funding constraints? Who are the most at risk and yet marginalised categories in our workplaces as well as the communities we serve? Who could make a difference to the epidemic rates if they are effectively targeted? Is it a concern that some communities
are currently not included in national responses? We should all remember that health is a right for all citizens. It is time that countries in the sub-Saharan Region did more than simply pay lip service to this idea.